Zurich Inpatriate Insurance. Product Disclosure Statement

Transcription

1 Zurich Inpatriate Insurance Product Disclosure Statement Preparation date: 10 September 2015 Effective date: 20 November 2015

2 Contents About our Inpatriate Insurance About Zurich... 2 How to apply for this insurance... 2 Our Inpatriate Insurance... 2 About an insured person... 3 Significant issues to consider... 3 Duty of Disclosure... 4 Cooling-off period... 4 How we calculate your premium... 5 Taxation... 5 How to make a claim... 6 Privacy... 6 Complaints and Disputes Resolution process... 6 General Insurance Code of Practice... 7 Financial Claims Scheme... 7 Headings... 7 Updating this PDS... 7 Benefits of cover available... 8 Inpatriate Insurance Policy Wording Definitions... 9 General Exclusions Applicable to All Sections Claims Procedures General Terms and Conditions Applicable to All Sections Section 1 Zurich Assist Emergency Assistance Services Section 2 Medical and Additional Expenses Section 3 Medical Repatriation and Emergency Evacuation Expenses Section 4 Personal Accident and Sickness Section 5 Personal Liability Additional Benefits ZU V3 09/15 - PCUS Page 1 of 32

3 About our Inpatriate Insurance About Zurich The insurer of this product is Zurich Australian Insurance Limited (ZAIL), ABN , AFS Licence Number In this document, ZAIL may also be expressed as Zurich, we, us or our. ZAIL is part of the Zurich Insurance Group, a leading multi-line insurance provider with a global network of subsidiaries and offices. With about 55,000 employees, the Zurich Insurance Group delivers a wide range of general insurance and life insurance products and services for individuals, small businesses, and mid-sized and large companies, including multinational corporations, in more than 170 countries. This Product Disclosure Statement (PDS) is an important document about this product and includes the policy wording which starts on page 9. You should read it carefully before making a decision to purchase this product. This PDS will help you to: decide whether this product will meet your needs; and compare this product with other products you may be considering. The information contained in this PDS is general information only. It is important you read your policy to ensure you have the cover you need. We capitalise or italicise terms in this PDS, to show that words are abbreviations or have a particular defined meaning. You should refer to the Definitions sections of this document to obtain the full meaning of such terms. How to apply for this insurance Throughout this document when we are referring to your insurance broker or adviser, we simply refer to them as your intermediary. If you are interested in buying this product or have any inquiries about it, you should contact your intermediary who should be able to provide you with all the information and assistance you require. If you are not satisfied with the information provided by your intermediary you can contact us at the address or telephone number shown on the back cover of this document. However, we are only able to provide factual information or general advice about the product. We do not give advice on whether the product is appropriate for your personal objectives, needs or financial situation. Our Inpatriate Insurance Zurich Inpatriate Insurance allows you to tailor the cover for your requirements. Cover can be arranged by you (referred to as the insured) to cover yourself or some other person(s) (referred to as the insured person(s)). The policy operates 24 hours a day, seven days a week, while an insured person is inpatriated to Australia, on the business of the insured. For a summary of additional benefits available to you, see Benefits of cover available on page 8. Our contract with you This policy is a contract of insurance between the insured and Zurich and contains all the details of the cover that we provide. The policy is made up of: the policy wording which begins at page 9 of this document. It tells you what is covered, sets out the claims procedure, exclusions and other terms and conditions of cover; the proposal, which is the information you provide to us when applying for insurance cover; your most current policy schedule issued by us. The schedule is a separate document unique to you, which shows the insurance details relevant to you. It includes any changes, exclusions, terms and conditions made to suit your individual circumstances and may amend the policy; and any other written change otherwise advised by us in writing (such as an endorsement or a supplementary PDS). These written changes vary or modify the above documents. Page 2 of 32

4 Please note, only those Sections shown as covered in your schedule are insured. This document is also the PDS for any offer of renewal we may make, unless we tell you otherwise. Please keep your policy in a safe place. We reserve the right to change the terms of this product where permitted to do so by law. About an insured person An insured person has a right to recover under this policy only through Section 48 of the Insurance Contracts Act 1984 (Cth) and is not a party to the contract of insurance. Only the insured is able to vary or cancel the Policy. When the insured person s cover starts and ends An insured person s ability to access cover: starts at the time the relevant person becomes an insured person; and ends when the relevant person no longer meets the criteria specified in the schedule for an insured person or at the end of the period of insurance (whichever is the earliest). Please refer to the Definitions section for the definition of period of insurance. Significant issues to consider Insurance contracts contain policy exclusions, policy terms and conditions and policy limits and sub-limits that you should be aware of when deciding to purchase our product. These things may affect the amount of the payment that we will make to you if you have a claim. We may express some policy terms, policy limits or sub-limits as being either a dollar amount or a percentage of your sum insured shown in your schedule or some other amount, factor or item specified in the relevant clause of this document. You should be aware of the following matters in considering whether this product is suitable for your needs. Excesses can apply An excess may apply to claims made under each of these Sections. An excess is not an additional fee, charged by us at the time of making a claim. Rather, it is the uninsured first portion of a loss for which you are otherwise covered, i.e. the amount that you must contribute towards each claim. We are able to provide options to quote higher or lower excess alternatives in certain circumstances, which will either decrease or increase your premium, depending upon the options requested. The excess applicable to your policy is specified in the schedule. There are also other excesses which are specified in the policy wording. Exclusions This policy contains a number of exclusions, some of which are common in insurance policies of this type. For example, we may not pay for death, injury, sickness, disability or loss arising from: the insured person being in an aircraft or aerial device, unless they are a passenger; war or civil war; or suicide, attempted suicide, or deliberately self-inflicted injury or sickness. Some of the exclusions may be less common, and as such may be unexpected. For example, this policy excludes cover for death, injury or sickness arising from the insured person training or participating in professional sport. Please refer to page 21 for the details of this exclusion. The above are some of the events that are not covered by this policy. Before making a decision about whether to purchase this policy, you should read the full details of all relevant exclusions, which are contained in the policy wording. Some may not be relevant to you however you should make yourself aware of all the exclusions that apply to all Sections. Please refer to General Exclusions Applicable to All Sections on page 11 and any additional exclusions specific to each Section. Page 3 of 32

5 Terms and Conditions General Terms and Conditions Applicable to All Sections set out your general obligations with which you need to comply. Please refer to page 13. Other terms and conditions relevant to each Section also apply and are explained in each section. You should read the policy wording and make yourself aware of all the terms and conditions that apply. If you do not meet them, we may be able to decline or reduce the claim payment or cancel your policy. Make sure you have the cover you need You should discuss with your intermediary the appropriate amounts and risks for which you need to be insured. If you do not adequately insure for the relevant risks you may have to bear any uninsured losses yourself. You should also advise your intermediary to notify us as soon as possible, when your circumstances change which are relevant to your policy. Duty of Disclosure For insureds who are not a natural person, before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms. You have this duty until we agree to insure you. You have the same duty before you renew, extend, vary or reinstate an insurance contract. You do not need to tell us anything that: reduces the risk we insure you for; or is common knowledge; or we know or should know as an insurer; or we waive your duty to tell us about. Individuals If you are the insured and you are a natural person, a different duty of disclosure to the one set out above applies to you. Contact your intermediary or us to ensure you are notified of your duty. If you do not tell us something If you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed. Cooling-off period After you apply for a Zurich product and you have received the policy document, you have 21 days to check that the policy meets your needs. Within this time you may cancel the policy and receive a full refund of any premium paid, unless you have: made a claim or become entitled to make a claim under your policy; or exercised any right or power you have in respect of your policy or the policy has ended. Your request will need to be in writing and forwarded to us via your intermediary or to the address shown on the back cover of this document. You can cancel your policy at any time after the cooling-off period. Please refer to Cancellation under General Terms and Conditions Applicable to All Sections on page 13. Page 4 of 32

6 How we calculate your premium The premium amount that you must pay for your insurance cover is set out in your policy schedule. The amount of your premium is determined by taking a number of different matters into account. You can seek quote at any time. It is important for you to know in particular that the premium varies depending on the information we receive from you about the risk to be covered by us. The higher the risk is, the higher the premium will be. Based on our experience and expertise as an insurer, we decide what factors increase our risk and how they should impact on the premium. Each insurer can do this differently. In this product the factors that are taken into consideration include the following: the business of the insured; the age of insured persons; the occupation of insured persons; the countries insured persons are being inpatriate from; benefit limits chosen; and the excess and/or annual aggregate excess amount you elect. This means that when you purchase a policy you may elect to take a larger excess or annual aggregate excess amount in the event of a claim, which will reduce the cost of your premium. If you are interested in this, you should ask your intermediary to supply you with quotes based on differing excess and annual aggregate excess amounts. Your intermediary can arrange for you to be provided with a quote for a premium. You will need to give your relevant personal details to your intermediary at this time to enable us to calculate the premium. Another important thing to know is that your premium also includes amounts that take into account our obligation to pay any relevant compulsory government charges, taxes or levies (e.g. Stamp Duty and GST) in relation to your policy. These amounts will be set out separately on your schedule as part of the total premium payable. How and when you pay your premium and what happens if you don t pay? Your premiums are charged and are payable on a yearly basis. Your intermediary can also tell you what other methods are available to make your premium payments. Your intermediary should send you an offer of renewal of your insurance once a year, before your current period of insurance expires. If you do not pay your premium when due, your policy may lapse after 30 days and you will not be covered. You may be able to reinstate your policy after it lapses, but you must submit an application to us, which is subject to our reassessment of your personal circumstances and the circumstances of all persons to be insured at the time of application. Taxation The following taxation information is a guide only and is based on the current law of Australia and its interpretation. Your individual circumstances will be important to and may affect the tax treatment of any premiums you pay or benefits you receive. You should consult your tax adviser regarding your individual circumstances. Income Tax Generally, if you are entitled to receive weekly benefits, the premium you pay may be tax deductible. Premiums may also be tax deductible if you have taken out your policy for a revenue purpose. Generally, if you receive weekly benefits, these benefits may be assessable to you and subject to tax at your marginal income tax rate. However, lump sum amounts that you receive are generally not taxable. This information is a guide only, and is based on current taxation laws, their continuation and their interpretation. For information about your individual circumstances, contact your tax adviser. Page 5 of 32

7 Goods and Services Tax Generally, you will not be required to pay Goods and Services Tax (GST) on any benefits you receive under your policy. However, you must advise us if you are entitled to claim an input tax credit in relation to any GST payable on your premium and the extent of that entitlement. If you do not provide this information to us, you may be liable to pay an amount of GST on benefits you receive. If you are registered for GST, any payment we make for funeral expenses, medical expenses, modification expenses or accommodation expenses will be reduced by the amount of any input tax credit you or another person are entitled to for those expenses. How to make a claim If you need to make a claim against this policy, please refer to Claims Procedures on page 12. If you have any queries, please contact your intermediary as soon as possible, or call us on Privacy Zurich is bound by the Privacy Act We collect, disclose and handle information, and in some cases personal or sensitive (eg health) information, about you ( your details ) to assess applications, administer policies, contact you, enhance our products and services and manage claims ( Purposes ). If you do not provide your information, we may not be able to do those things. By providing us, our representatives or your intermediary with information, you consent to us using, disclosing to third parties and collecting from third parties your details for the Purposes. We may disclose your details, including your sensitive information, to relevant third parties including your intermediary, affiliates of Zurich Insurance Group Ltd, other insurers and reinsurers, our service providers, our business partners, health practitioners, your employer, parties affected by claims, government bodies, regulators, law enforcement bodies and as required by law, within Australia and overseas. We may obtain your details from relevant third parties, including those listed above. Before giving us information about another person, please give them a copy of this document. Laws authorising or requiring us to collect information include the Insurance Contracts Act 1984, Anti-Money Laundering and Counter-Terrorism Financing Act 2006, Corporations Act 2001, Autonomous Sanctions Act 2011, A New Tax System (Goods and Services Tax) Act 1999 and other financial services, crime prevention, trade sanctions and tax laws. Zurich s Privacy Policy, available at or by telephoning us on , provides further information and lists service providers, business partners and countries in which recipients of your details are likely to be located. It also sets out how we handle complaints and how you can access or correct your details or make a complaint. Complaints and Disputes Resolution process If you have a complaint about an insurance product we have issued or service you have received from us, please contact your intermediary to initiate the complaint with us. If you are unable to contact your intermediary, you can contact us directly on We will respond to your complaint within 15 working days. If you are not satisfied with our response, you may have the matter reviewed through our internal dispute resolution process, which is free of charge. If you are not satisfied with the outcome of the dispute resolution process and would like to take the complaint further, you may refer the matter to the Financial Ombudsman Service (FOS) Australia, an independent and external dispute resolution scheme. The FOS Australia is free of charge to you. FOS Australia contact details are: The Financial Ombudsman Service Limited Post: GPO Box 3, Melbourne, Victoria 3001 Freecall: or 1800 FOS AUS Website: info@fos.org.au Page 6 of 32

8 General Insurance Code of Practice We are signatories to the General Insurance Code of Practice which was developed by the Insurance Council of Australia to further raise standards of practice and service across the insurance industry. You can obtain more information on the Code and how it assists you by contacting us. Financial Claims Scheme Zurich is an insurance company authorised under the Insurance Act 1973 to carry on general insurance business in Australia. As such, we are subject to prudential requirements and standards, regulated by the Australian Prudential Regulation Authority (APRA). This policy may be a protected policy under the Federal Government s Financial Claims Scheme, (FCS) which is administered by APRA. The FCS may apply in the event that a general insurance company becomes insolvent. If the FCS applies, a person who is entitled to make a claim under this insurance policy may be entitled to a payment under the FCS. Access to the FCS is subject to eligibility criteria. Further information about the FCS can be obtained from the APRA website at and the APRA hotline on Headings Headings have been included for ease of reference, but do not form part of the policy. Updating this PDS The information in this PDS is up to date at the time it is prepared. Certain information in this PDS may change from time to time. If the updated information is not materially adverse from the point of view of a reasonable person deciding whether or not to purchase this product, we will update this information on our website at A paper copy of the updated information will be available free of charge upon request, by contacting your intermediary or us by using our contact details on the back cover of this PDS. Please note that we may choose to issue a new or supplementary PDS in other circumstances. Page 7 of 32

9 Benefits of cover available The following table shows highlights of some of the major benefits available under the policy. Exclusions, limits and conditions apply so please refer to each Sections for full details of coverage. Types of covers available Benefits of cover available Page no Section 1 Zurich Assist Emergency Assistance Services Zurich Assist Emergency Assistance Services Access to Zurich Assist: an emergency assistance service that can be accessed any time, anywhere in the world. Zurich Assist has access to a worldwide team of skilled doctors, medical professional and other emergency assistance consultants, available 24 hours a day, 7 days a week 15 Section 2 Medical and additional expenses Medical and additional expenses Provides cover for medical and additional expenses, such as those described below, incurred by the insured person following bodily injury or sickness and incurred during the period of insurance: private hospital expenses public hospital expenses maternity expenses dental expenses ancillary expenses emergency transport expenses rehabilitation expenses psychiatry expenses psychology expenses 16 Section 3 Medical Repatriation and Emergency Evacuation expenses Medical repatriation and emergency evacuation expenses Benefits include reasonable expenses incurred for medical repatriation and emergency evacuation, such as those described below, incurred by an insured person following injury or sickness and incurred during the period of insurance: airfares (economy where possible) in transporting insured persons to the nearest recommended hospital airfares in transporting an adult to accompany an insured person under the age of 16 who is being repatriated pre and post hospitalisation accommodation 23 Section 4 Personal Accident and Sickness Accidental Death and Capital Benefits Weekly Injury Benefits Weekly Sickness Benefits Section 5 Personal Liability Personal liability Benefits payable in the event that the insured person suffers accidental death or injury as a result of an accident Weekly benefits payable in the event an insured person suffers temporary total disablement or temporary partial disablement, as a result of an injury Weekly benefits payable in the event an insured person suffers temporary total disablement or temporary partial disablement, as a result of sickness during the period of insurance We will indemnify the insured person for all sums which they become legally liable to pay for damages in respect of personal injury and/or property damage to a third party, during the period of insurance Page 8 of 32

10 Inpatriate Insurance Policy Wording Subject to the terms and conditions contained in this policy, we will cover insured persons for the events described in the Sections of this policy, but only if: 1. you have paid or agreed to pay the premium set out in your schedule; and 2. the type of cover is specified in your schedule as applying to that insured person. Definitions For the purpose of the policy, the following definitions apply: Accident accident means a single event that is: (c) caused by violent, external and visible means (independently of any other cause); and which results in injury that is both unexpected and undesired by an insured person; and which occurs during the period of insurance. Civil war civil war means a state of armed conflict or rebellion, insurrection, revolution or sedition between different parties belonging to the same country using military like force to achieve economic, geographic, nationalistic, political, racial, religious or other ends. Close family member close family member means the insured person s spouse or partner, child, step child, brother, step brother, sister, step sister, parent, aunt, uncle, nephew, niece, grandchild or grandparent. Country of Domicile country of domicile means the country where the insured person(s) is/are residing temporarily on foreign assignment for business purposes, on the business of the insured. Country of Residence country of residence means the country of which the insured person is naturalised, a citizen or permanent resident (i.e. holder of a multiple entry visa or permit which gives the insured person resident health care rights in such country) at the effective date of cover and each subsequent period of insurance. Dependent children dependent children means the insured person s unmarried children who are under the age of: 19 years and living with the insured person; or 25 years and a full time student at an accredited institute of higher learning in the country of domicile, and who are primarily dependent on the insured person for their maintenance and support. Dependent children also includes an insured person s unmarried child of any age who is physically or mentally incapable of self-support provided they are permanently living with the insured person in the country of domicile. Effective date of cover effective date of cover means the date on which: a insured person first meets the criteria set out for a insured person in the schedule; and premium is paid or agreed to be paid by the insured for the insured person. Page 9 of 32

11 Emergency transport expenses emergency transport expenses means expenses incurred to transport a insured person to a public hospital. For the purpose of clarity, this definition is intended to include inter-hospital transfers that are necessary because the original admitting public hospital does not have the required clinical facilities. It does not extend to transfers due to insured person(s) preferences. Excess excess means the amount we will not pay in any one period of insurance per single, couple or family and which the insured person is required to bear themselves. This amount is stated in the schedule either expressed as a monetary amount or as a percentage of the loss. Home leave home leave means leave where the insured person temporarily returns to their country of residence. Injury injury means loss of life or injury resulting from an accident. Injury does not include sickness arising out of an accident. Insured insured means the Insured specified in the schedule as the insured; i.e. the policyholder of this policy. Insured person insured person means any person shown in the schedule as an insured person and/or as nominated by the insured and agreed to by us for eligibility under this policy from time to time with respect to whom premium has been paid or agreed to be paid. Period of Insurance period of insurance means the period shown on the current schedule or such shorter time if the policy is terminated. Pre-existing condition pre-existing condition means: any condition for which a medical practitioner was consulted or for which treatment or medication was prescribed prior to the effective date of cover; or a condition or symptoms of which a reasonable person in the circumstances would be expected to be aware of within three months prior to their effective date of cover. Professional sport professional sport means any sport in which an insured person receives financial reward, sponsorship or gain as a result of their participation. Recognised health provider recognised health provider means Chartis, Chubb, ACE Insurance, Accident & Health International or other international health providers, including Australian registered health funds. Rehabilitation expenses rehabilitation expenses means the reasonable and necessary charges incurred by a insured person during the period of insurance and after the insured person s effective date of cover for their rehabilitation treatment and/or occupational therapy as prescribed by the treating medical practitioner or specialist as a result of a injury or sickness. Schedule schedule means the relevant Schedule issued by us to the insured. Page 10 of 32

12 Sickness sickness means any illness, disease or syndrome which does not include a pre-existing condition where takeover provisions have not been met, suffered by the insured person for which they first become aware of symptoms or are advised to seek medical attention or tests, or a reasonable person in the circumstances would have become aware of or would have sought medical attention or tests, during the period of insurance. Spouse or Partner spouse or partner means a person who is married to the insured person or a partner of an insured person who has been co-habiting with the insured person for a period of at least three continuous months and is living with the insured person in country of domicile. Sum insured sum insured means the amount for which you are insured, as specified in your schedule. Takeover provisions takeover provisions means coverage under Sections 1, 2 and 3 of this policy is extended to include all pre-existing conditions excluding pregnancy, provided an insured person has been continuously insured with a recognised health provider in the 12 months immediately prior to becoming an insured person of this policy. Such cover shall not extend to any conditions or treatments which were excluded under the insured person s previous insurance held with a recognised health provider. Very seriously ill very seriously ill means a medical condition certified by the attending medical practitioner or specialist to be of such a serious nature as to warrant a notification to relatives that their attendance is desirable in view of the serious nature of the condition and threat to the insured person s life. Waiting period waiting period means the period of (12) calendar months from the relevant insured person s effective date of cover. This waiting period does not apply to an insured person where the takeover provisions have been met by the insured person. War war means a state of armed conflict between different nations, states or armed groups using military force to achieve economic, geographic, nationalistic, political, racial, religious or other ends. You / Your you / your means the insured. General Exclusions Applicable to All Sections We will not pay any benefits where death, injury, sickness, bodily injury, disability or liability arises from or is caused directly or indirectly from: 1. an insured person being over the age of 70 years; 2. any pre-existing condition, except where take-over provisions have been met; 3. professional services rendered in Australia where benefits are payable in accordance with Medicare or the Private Health Insurance Act 2007 (Cth); 4. any elective cosmetic or plastic surgery, except to the extent that it is necessary as a result of injury or sickness, or for the cure or alleviation of injury to the insured person; 5. radioactivity, or the use, existence or escape of any nuclear fuel, nuclear material or nuclear waste. Page 11 of 32

13 Claims Procedures 1. In the event of a claim In the event of a claim, you must: (c) tell us what happened immediately. You can contact us on or contact your intermediary, as soon as practicable; complete our claim form and send it to us promptly if we request it; and provide any other information or help which we may request to support your claim. Where an accident causing injury, sickness or disability to an insured person occurs, the insured person must: (d) (e) obtain and follow medical advice, including undertaking treatment, as prescribed from a medical practitioner; and obtain a certificate from a medical practitioner confirming the nature and extent of the injury, bodily injury, sickness or disability. After you have made a claim under your policy, we have the sole right to act in your name and on your behalf to negotiate or settle any claim. If we do this, it will be at our expense. You must give us all the help and information we need to pursue these claims. 2. Reporting period You must provide us with written notice of any occurrence likely to give rise to a claim within 30 days or soon as reasonably practicable after the date of the occurrence. 3. After your claim is accepted After we have paid a claim under your policy, either in total or in part, we have the right to takeover any legal right of recovery which you have. If we do this, it will be for our benefit and at our expense (if you have been fully reimbursed). You must provide full cooperation. 4. Payments in respect of Goods and Services Tax When we make a payment to you or on your behalf, under your policy for the acquisition of goods, services or other supply, we will reduce the amount of the payment by the amount of any input tax credit that you are, or will be, or would have been entitled to under A New Tax System (Goods and Services Tax) Act 1999, in relation to that acquisition, whether or not that acquisition is actually made. When we make a payment to you or on your behalf, under your policy as compensation instead of payment for the acquisition of goods, services or other supply, we will reduce the amount of the payment by the amount of any input tax credit that you are, or will be, or would have been entitled to under A New Tax System (Goods and Services Tax) Act 1999 had the payment been applied to acquire such goods, services or supply. 5. Progress payments If we have agreed that a claim is covered by your policy we will make reasonable progress payments. Page 12 of 32

14 General Terms and Conditions Applicable to All Sections The following general terms and conditions apply to your policy: 1. Precautions You must take all reasonable care to prevent or minimise loss, damage, injury, sickness or liability, including your compliance with any law, by-law, ordinance or regulation that concerns the safety of persons or property. 2. Medical examination or post mortem We will be entitled at our expense to have any insured person medically examined or in the event of death, a post mortem examination carried out. We will give the insured person or their legal representative reasonable notice of the medical examination. 3. Automatic extension of cover We will automatically extend the insured person s cover under this policy for 3 calendar months from the date of the insured person s original expected return to their country of residence if their return travel is delayed due to delay of transport which is out of the control of the insured person or due to the insured person s inability to travel due to an injury or sickness for which a claim is payable under this policy. 4. Cancellation You may cancel this policy at any time by notifying us in writing. Notice of cancellation has the effect of cancelling this policy at 4.00pm on the day we receive your written notice or such later date you request. We may cancel this policy by notifying you in writing, if you are in breach of any of the terms or conditions, or for any other reason available at law. Notice of cancellation has the effect of cancelling this policy at 4.00pm on the 30th business day, after the day on which notice was sent to you. (c) (i) After cancellation by you, we will be entitled to retain: (ii) (1) one and a half times the pro rata premium for the period during which the policy has been in force; and (2) any tax or duty paid or owing for which we are unable to obtain a refund. After cancellation by us, you will be entitled to a refund on a pro rata basis in relation to the unexpired period of insurance. You will not receive a refund if you have made a claim or you become entitled to make a claim under the policy which is greater than 65% of the premium paid. 5. Fraudulent claims If you or any party covered by your policy makes a claim or arranges for some other party to make a claim that is in any way false, dishonest or fraudulent, then payment of the claim may be refused. 6. Other insurance and contribution When you make a claim on your policy you must also supply us with written details of all other insurance policies that may also pay or partially pay that claim. 7. Alteration of risk You must tell us as soon as possible if circumstances occur, or if changes or alterations are intended or made which increase the risk of loss, damage, injury, bodily injury, sickness or liability. 8. Notifications All notices and communications to us must be made or confirmed in writing by you and sent to our office where your policy was issued. Other forms of communication will not be acted upon by us until confirmed in writing by you. Page 13 of 32

15 9. Proper law and jurisdiction The construction, interpretation and meaning of the provisions of this policy will be determined in accordance with Australian law. In the event of any dispute arising under this policy, including but not limited to its construction and/or validity and/ or performance and/or interpretation, you will submit to the exclusive jurisdiction of any competent court in the Commonwealth of Australia. 10. Subrogation You and all insured persons will at any time, at our request and expense, permit all reasonable steps required to enforce any rights to which we would be entitled, including but not limited to any necessary steps required to prosecute a person or group responsible for any unauthorised acts against an insured person. 11. Sanctions regulation Notwithstanding any other terms or conditions under this policy, Zurich shall not be deemed to provide coverage and will not make any payments nor provide any service or benefit to you or any other party to the extent that such cover, payment, service, benefit and/or any business or activity of yours would violate any applicable trade or economic sanctions, law or regulation. 12. Currency All amounts under this policy are expressed and payable in Australian currency. Except as otherwise provided, if a judgment is rendered, settlement is denominated or another element of loss under this policy is stated in a currency other than Australian dollars, payment under this policy will be made in Australian dollars at the cash rate of exchange for the purchase of Australian dollars in accordance with the Reserve Bank of Australia on the date the final judgment is reached, the amount of the settlement is agreed upon or the other element of loss is due, respectively. 13. Renewal This policy may be renewed with our consent provided you pay or agree to pay the required renewal premium. 14. Plurals and Titles The submission, this policy, its schedule and any endorsements are one contract in which, unless the context otherwise requires: (c) headings are descriptive only, not an aid to interpretation; singular includes the plural, and vice versa; and the male includes the female and neuter. Page 14 of 32

16 Section 1 Zurich Assist Emergency Assistance Service Cover In the event of a medical or other emergency during the period of insurance, an insured person has access to Zurich Assist. Zurich Assist is an emergency assistance service that can be accessed by an insured person any time without additional charge to the insured person, anywhere in the world by calling (by reverse charge if required). Zurich Assist has a worldwide team of skilled doctors, medical professionals and other emergency assistance consultants, available 24 hours a day, 7 days a week. With our approval, Zurich Assist can provide help to an insured person with services including: access to medical practitioner for emergency assistance and advice; their emergency medical evacuation as a direct result of their injury or sickness, including accompanying medical staff; arranging for close family members or accompanying travelling companions to travel to or remain with an insured person who has suffered an injury or sickness; repatriating an insured person to a more suitable hospital or back to the insured person s country of residence as a direct result of them suffering an injury or sickness; keeping close family members informed of the insured person s medical condition; payment guarantees to hospitals and insurance verification; second opinions on medical matters; medical monitoring; Conditions 1. You and/or the insured person must not attempt to resolve problems encountered without first advising us and/or Zurich Assist. 2. In the event of emergency assistance services being provided by Zurich Assist in good faith to any person not insured under this policy, you shall reimburse us for all costs incurred. 3. We reserve our rights against any insured person who does not make contact with us and/or Zurich Assist and/or prejudices our rights. 4. In accepting the services of Zurich Assist, you and the insured person acknowledge that the insured person s attending physician has the ultimate responsibility for the care and treatment of the insured person. Zurich Assist can only provide such assistance as the insured person s attending physician believes to be in the insured person s interest. Exclusions In addition to the General Exclusions Applicable to All Sections on page 11, we will not be liable for any expenses: 1. recoverable by you and/or the insured person from any other source (with the exception of other insurance); 2. incurred directly or indirectly as a result of any medication for treatment of a condition the insured person had prior to the effective date of cover. This exclusion shall not apply if takeover provisions have been met; or 3. any expenses or charges incurred after you or the insured person, or any of your or the insured person s representatives refuse to follow the instructions and directions of us or Zurich Assist. Page 15 of 32

17 Section 2 Medical and Additional Expenses Cover We will pay the necessary and reasonable expenses actually incurred by an insured person during the period of insurance for those medical and additional expenses described in the following Table of Benefits up to the maximum amounts shown under Benefit amount in the Table of Benefits below. Table of Benefits The maximum benefit amounts shown below are the maximum payable per insured person in any one period of insurance and all benefit amounts are limited by the sum insured stated in the schedule under Medical and Additional Expenses. Expenses Medical primary and Specialist outpatient care expenses public hospital expenses private hospital expenses (Please refer to the Exclusions relating to Private hospital expenses) doctor s and/or specialist charges day care expenses prosthesis preventative medical expenses $5,000 Expenses Maternity expenses maternity care and treatment routine expenses provided in a public hospital maternity care and treatment routine expenses provided in a private hospital maternity care and treatment emergency expenses provided in a public hospital maternity care and treatment emergency expenses provided in a private hospital Benefit amount 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of actual expenses up to the maximum amount listed in the Private Health Insurance (Prostheses) Rules 2007 for the prosthesis required. Maternity Expenses Amounts shown under Maternity expenses are the maximum payable per insured person for any one period of insurance. Insured person(s) are only covered for maternity expenses if: the pregnancy commences during the period of insurance and after their effective date of cover and no waiting period applies (or the waiting period has expired); or the takeover provisions have been met. Benefit amount 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of actual expenses up to a maximum of $10, % of actual expenses up to the amount stated in the schedule under Section 2 100% of actual expenses up to a maximum of $10,000 new born child expenses 100% of actual expenses up to a maximum of $10,000 Page 16 of 32

18 Dental expenses Amounts shown in Dental expenses are the maximum payable per insured person for any one period of insurance. Expenses Benefit amount Dental expenses dental services (emergency) 100% of actual expenses up to the amount stated in the schedule under Section 2 dental expenses (general) 85% of actual expenses up to $1,500 dental expenses (special) 85% of actual expenses up to $1,500 Ancillary expenses Amounts shown in ancillary expenses are the maximum payable per insured person for any one period of insurance. Expenses Benefit amount Ancillary expenses acupuncture/naturopathy/hypnotherapy 100% of actual expenses up to $1,000 chiropractic/osteopathy $100 per visit up to a maximum of $1,000 dietetics 100% of actual expenses up to $1,000 hearing aid(s) 100% of actual expenses up to $1,000 optical expenses 100% of actual expenses up to $600 physiotherapy $100 per visit up to a maximum of $1,500 podiatry 100% of actual expenses up to $1,000 pharmaceutical charges 100% of actual expenses up to the amount stated in the schedule under Section 2 prescribed medicines 100% of actual expenses up to $2,200 remedial massage 100% of actual expenses up to $500 speech therapy 100% of actual expenses up to $500 home nursing expenses 100% of actual expenses up to a maximum of $1,000 per week (limited to a maximum period of 4 weeks) Other expenses Amounts shown in Other expenses are the maximum payable per insured person for any one period of insurance. Expenses Benefit amount Other expenses rehabilitation expenses 100% of the actual costs up to $10,000 emergency transport expenses psychiatry expenses: Incurred as an inpatient Incurred as an outpatient 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of the actual costs up to $2,500 psychology expenses: Incurred as an inpatient Incurred as an outpatient 100% of actual expenses up to the amount stated in the schedule under Section 2 100% of the actual costs up to $2,500 Page 17 of 32

19 Definitions Anaesthetic charges anaesthetic charges means charges made for an anaesthetic and its administration including medical practitioner fees. Ancillary expenses ancillary expenses means the reasonable and necessarily incurred charges for ancillary services such as: (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) acupuncture; naturopathy; hypnotherapy; chiropractic; osteopathy; dietetics; optical expenses; physiotherapy; podiatry; prescribed medicines; hearing aids; speech therapy; and (m) remedial massage. Bodily injury bodily injury means a bodily injury resulting solely from an accident and which occurs independently of any illness or other cause: where the bodily injury and accident both occur during the period of insurance and whilst the person is an insured person; or the ongoing treatment of a bodily injury occurring prior to the insured person s effective date of cover where the takeover provisions have been met, provided that the treatment was covered and accepted as being covered under the policy of the preceding recognised health provider or by us. It does not mean: (i) (ii) a sickness or illness or disease; or any pre-existing condition (except): (1) illness or disease directly resulting from medical or surgical treatment rendered necessary by any bodily injury; or (2) where the takeover provisions or the applicable waiting periods have been met in relation to the pre-existing condition. Day care expenses day care expenses means medical expenses of an insured person for which prior approval has been obtained from Zurich Assist for medical treatment provided in a hospital or in a specially equipped clinic or treatment centre which: (c) does not require the insured person to be confined in a hospital for a period greater than 24 hours; and is provided by a specialist or under the direct supervision of a specialist; and includes surgery performed by medical practitioner or specialists. Dental services (emergency) dental services (emergency) means charges made by a duly qualified oral surgeon or dentist for non routine treatment to a insured person s healthy teeth which are damaged as a result of a bodily injury. Page 18 of 32

20 Dental expenses (general) dental expenses (general) means charges made by a duly qualified oral surgeon or dentist for examinations, scaling and cleaning, dental filling and restorations, diagnostic services, X-Rays, injections and extractions of teeth. Dental expenses (special) dental expenses (special) means charges made by a duly qualified oral surgeon or dentist for root treatment, endodontic treatment, oral surgery, anaesthetic services, periodontic surgery, interceptive orthodontic services, installation of and repairs to crowns and bridges, new dentures, dental repairs and remodelling and other specialist and orthodontic services. Dentist dentist means a dentist or specialist who is registered or licensed to practice dentistry under the laws of the country in which they practice, other than: (c) (d) the insured; the insured person; a close family member of the insured person; or an employee or director of the insured. Home nursing expenses home nursing expenses means charges incurred by a insured person during the period of insurance and after the insured person s effective date of cover for the treatment of their bodily injury or sickness, provided the care is considered necessary as evidenced by a written statement from a medical practitioner and provided by a person registered as a nurse who is not: (c) (d) the insured; the insured person; a close family member of the insured person; or an employee or director of the insured. Maternity care and Treatment emergency expenses maternity care and treatment emergency expenses means emergency and/or complicated delivery charges for medical emergencies or complications resulting from pregnancy or childbirth, including emergency and unplanned caesarean procedures, intrapartum complications and complications relating to placentation. Maternity care and Treatment routine expenses maternity care and treatment routine expenses means charges for routine pre-natal, delivery (including elective caesarean) and post-natal charges (up to 6 months after the birth of the child) for the care of the mother from the date of conception (or known conception) provided that the insured person s pregnancy commenced during the period of insurance and after their effective date of cover. Maternity expenses maternity expenses means maternity care and treatment emergency expenses, maternity care and treatment routine expenses and new born child expenses. Medical practitioner medical practitioner means a person qualified and who is registered or licensed to practice medicine under the laws of the country in which they practice, other than: (c) (d) the insured; the insured person; a close family member of the insured person; or an employee or director of the insured. Page 19 of 32